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* DATE:

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* SCHOOL:

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* GRADE LEVEL:

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* AGE:

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* 1. Are you a .....?

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* 2. What is your race/ethnicity? (Please choose only one).

For each statement below, please mark what best represents your opinion:

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* 3. Mental health is your feelings, thoughts, and actions.

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* 4. I know when I feel mad, sad, or worried.

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* 5. I know what to do to keep my feelings, thoughts, and actions healthy.

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* 6. I know trusted adults I can talk to about my feelings and thoughts.

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* 7. I feel comfortable talking to a trusted adult about my feelings and thoughts.

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* 8. Who is your trusted adult(s):

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